Adenomyosis and association between ultrasonographic features and pregnancy outcomes in women with infertility or pregnancy loss: a systematic review and meta-analysis
Abstract
Background: Adenomyosis has been shown to reduce live birth rates and increase the risk of pregnancy loss. The diagnosis is often established by ultrasonographic assessment using the revised Morphological Uterus Sonographic Assessment (MUSA) criteria. However, the reproductive impact of specific sonographic features remains unclear. A systematic review and meta-analysis was conducted to investigate whether individual ultrasonographic adenomyosis features influence pregnancy outcomes in women with infertility or pregnancy loss.
Methods: We searched MEDLINE (PubMed), Embase, Cochrane Library (CENTRAL), Web of Science, Scopus, and Google Scholar (most recent 200 records) from inception to May 11th, 2026. Observational and interventional studies reporting specific ultrasonographic features of adenomyosis in women with infertility and/or pregnancy loss were included. Primary outcomes were clinical pregnancy, live birth, and pregnancy loss. Two reviewers independently extracted data and assessed risk of bias using the Newcastle–Ottawa Scale and Joanna Briggs Institute critical appraisal tools, as appropriate by study design. Meta-analyses were performed using random-effects models, with common-effects models applied where appropriate; remaining evidence was synthesised narratively. Certainty of evidence was assessed by GRADE. The protocol was registered on PROSPERO (CRD420251077005).
Findings: Of 2322 records screened, 29 studies comprising 19,510 patients (7569 with adenomyosis) were included. Diffuse adenomyosis was associated with lower odds of live birth compared with no adenomyosis (OR 0.52, 95% CI 0.34–0.79; I2 = 63%), as well as internal adenomyosis compared with no adenomyosis (OR 0.49 95% CI 0.42–0.57 I2 = 0%). Narrative synthesis suggested poorer reproductive outcomes with adenomyosis features located near the endometrium and with larger uterine volume. The overall certainty was low or very low for 20 out of 21 outcomes, and moderate for one, primarily driven by imprecision and indirectness related to variation in diagnostic criteria across studies.
Interpretation: Reproductive outcomes in adenomyosis vary according to specific ultrasonographic features, supporting feature-based reporting beyond a binary diagnosis. Substantial clinical and methodological heterogeneity, including inconsistent ultrasonographic diagnostic criteria, variable application of MUSA definitions, and differences in fertility treatment protocols, warrants cautious interpretation of pooled estimates. Standardised definitions and reporting of adenomyosis features are needed to improve evidence synthesis and clinical translation.
Funding: The Novo Nordisk Foundation and the Danish Research Council.
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BibTeX
@article{brandt2026adenomyosis,
title = {{Adenomyosis and association between ultrasonographic features and pregnancy outcomes in women with infertility or pregnancy loss: a systematic review and meta-analysis}},
author = {Nicolaj Bruun Brandt and Cecilia Lindner and Karen Høgh Abrahamsen and Giuliana Beneduce and Sofie Bliddal and David Westergaard and Steen Joop Bonnema and Marianne Skovsager Andersen and Pernille Ravn and Dorte Glintborg and Henriette Svarre Nielsen},
journal = {eBioMedicine},
year = {2026},
month = oct,
doi = {10.1016/j.ebiom.2026.106518},
url = {https://linkinghub.elsevier.com/retrieve/pii/S2352396426004020},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Adenomyosis and association between ultrasonographic features and pregnancy outcomes in women with infertility or pregnancy loss: a systematic review and meta-analysis
AU - Nicolaj Bruun Brandt
AU - Cecilia Lindner
AU - Karen Høgh Abrahamsen
AU - Giuliana Beneduce
AU - Sofie Bliddal
AU - David Westergaard
AU - Steen Joop Bonnema
AU - Marianne Skovsager Andersen
AU - Pernille Ravn
AU - Dorte Glintborg
AU - Henriette Svarre Nielsen
PY - 2026
DA - 2026/10/21
JO - eBioMedicine
DO - 10.1016/j.ebiom.2026.106518
UR - https://linkinghub.elsevier.com/retrieve/pii/S2352396426004020
AB - Background: Adenomyosis has been shown to reduce live birth rates and increase the risk of pregnancy loss. The diagnosis is often established by ultrasonographic assessment using the revised Morphological Uterus Sonographic Assessment (MUSA) criteria. However, the reproductive impact of specific sonographic features remains unclear. A systematic review and meta-analysis was conducted to investigate whether individual ultrasonographic adenomyosis features influence pregnancy outcomes in women with infertility or pregnancy loss. Methods: We searched MEDLINE (PubMed), Embase, Cochrane Library (CENTRAL), Web of Science, Scopus, and Google Scholar (most recent 200 records) from inception to May 11th, 2026. Observational and interventional studies reporting specific ultrasonographic features of adenomyosis in women with infertility and/or pregnancy loss were included. Primary outcomes were clinical pregnancy, live birth, and pregnancy loss. Two reviewers independently extracted data and assessed risk of bias using the Newcastle–Ottawa Scale and Joanna Briggs Institute critical appraisal tools, as appropriate by study design. Meta-analyses were performed using random-effects models, with common-effects models applied where appropriate; remaining evidence was synthesised narratively. Certainty of evidence was assessed by GRADE. The protocol was registered on PROSPERO (CRD420251077005). Findings: Of 2322 records screened, 29 studies comprising 19,510 patients (7569 with adenomyosis) were included. Diffuse adenomyosis was associated with lower odds of live birth compared with no adenomyosis (OR 0.52, 95% CI 0.34–0.79; I2 = 63%), as well as internal adenomyosis compared with no adenomyosis (OR 0.49 95% CI 0.42–0.57 I2 = 0%). Narrative synthesis suggested poorer reproductive outcomes with adenomyosis features located near the endometrium and with larger uterine volume. The overall certainty was low or very low for 20 out of 21 outcomes, and moderate for one, primarily driven by imprecision and indirectness related to variation in diagnostic criteria across studies. Interpretation: Reproductive outcomes in adenomyosis vary according to specific ultrasonographic features, supporting feature-based reporting beyond a binary diagnosis. Substantial clinical and methodological heterogeneity, including inconsistent ultrasonographic diagnostic criteria, variable application of MUSA definitions, and differences in fertility treatment protocols, warrants cautious interpretation of pooled estimates. Standardised definitions and reporting of adenomyosis features are needed to improve evidence synthesis and clinical translation. Funding: The Novo Nordisk Foundation and the Danish Research Council.
SN - 2352-3964
ER -